Provider Demographics
NPI:1245204965
Name:MONTERUSSO, KAREN ARDEL (PA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:ARDEL
Last Name:MONTERUSSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:ARDEL
Other - Last Name:SCHUMAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:3299 N WELLNESS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-7270
Mailing Address - Country:US
Mailing Address - Phone:616-738-3884
Mailing Address - Fax:
Practice Address - Street 1:3299 N WELLNESS DR STE 150
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7270
Practice Address - Country:US
Practice Address - Phone:616-738-3884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110D111790OtherBCBSM
MI110D111790OtherBCBSM
N48650042Medicare ID - Type Unspecified